title: Shoshin beriberi mimicking a high-risk non-ST-segment elevation acute coronary syndrome with cardiogenic shock: when the arteries are not guilty.
abstract: BACKGROUND
  Cardiac acute beriberi (Shoshin syndrome) is a rare disease that may lead to a fatal outcome if not treated specifically.
  
  
  OBJECTIVE
  We report a case of Shoshin syndrome with an unusual presentation of cardiogenic shock and an electrocardiographic pattern of severe myocardial ischemia suggesting left main coronary artery obstruction.
  
  
  METHODS
  A 35-year-old man presented with chest discomfort, diffuse ST-segment depression in the 12-lead electrocardiogram (ECG) with ST-segment elevation in aVR, and rapidly evolving congestive heart failure leading to cardiogenic shock. Intensive support was required, including mechanical ventilation, high doses of inotropics and vasopressors, intra-aortic balloon counterpulsation, and continuous renal replacement therapy. An emergency coronary angiogram was performed that showed normal coronary arteries. Right heart catheterization showed a high-output state with elevated filling pressures suggesting high-output heart failure. The echocardiography confirmed normal left and right ventricular contraction. Thiamine deficiency was suspected as the cause of the high-output heart failure. After a single dose of intravenous thiamine (100 mg), the patient's hemodynamic status improved dramatically within minutes, allowing a rapid discontinuation of hemodynamic support. Subsequent ECGs showed complete resolution of ST-segment abnormalities. Serial lactate measurements, red blood cell transketolase activity, and the thiamine pyrophosphate response test were concordant with a thiamine deficiency state.
  
  
  CONCLUSIONS
  Shoshin syndrome may present as cardiogenic shock with an ECG mimicking severe myocardial ischemia, and if suspected, can be rapidly and effectively treated.
authors.affiliation: Unidad Coronaria, Servicio de Cardiología, Hospital Clínic, Barcelona, Spain.
authors.forename: Pablo
authors.initials: P
authors.lastname: Loma-Osorio
authors.forename: Pablo
authors.initials: P
authors.lastname: Peñafiel
authors.forename: Ada
authors.initials: A
authors.lastname: Doltra
authors.forename: Alessandro
authors.initials: A
authors.lastname: Sionis
authors.forename: Xavier
authors.initials: X
authors.lastname: Bosch
mesh_terms: D054058:Acute Coronary Syndrome / Q000209:etiology* / Q000503:physiopathology; D000328:Adult; D001157:Arterial Occlusive Diseases / Q000150:complications; D001602:Beriberi / Q000150:complications* / Q000503:physiopathology; D003331:Coronary Vessels; D003937:Diagnosis, Differential; D004562:Electrocardiography; D006801:Humans; D008297:Male; D012770:Shock, Cardiogenic / Q000209:etiology* / Q000503:physiopathology